Design, dissemination, and evaluation of an advanced communication elective at seven U.S. medical schools.

PURPOSE: To test educational methods that continue communication training into the fourth year of medical school. METHOD: The authors disseminated and evaluated an advanced communication elective in seven U.S. medical schools between 2007 and 2009; a total of 9 faculty and 22 fourth-year students participated. The elective emphasized peer learning, practice with real patients, direct observation, and applications of video technology. The authors used qualitative and quantitative survey methods and video review to evaluate the experience of students and faculty. RESULTS: Students reported that the elective was better than most medical school clerkships they had experienced. Their self-confidence in time management and in the use of nine communication skills improved significantly. The most valued course components were video review, repeated practice with real patients, and peer observation. Analysis of student videos with real patients and in role-plays showed that some skills (e.g., agenda setting, understanding the patient perspective) were more frequently demonstrated than others (e.g., exploring family and cultural values, communication while using the electronic health record). Faculty highly valued this learner-centered model and reported that their self-awareness and communication skills grew as teachers and as clinicians. CONCLUSIONS: Learner-centered methods such as peer observation and video review and editing may strengthen communication training and reinforce skills introduced earlier in medical education. The course design may counteract a "hidden curriculum" that devalues respectful interactions with trainees and patients. Future research should assess the impact of course elements on skill retention, attitudes for lifelong learning, and patients' health outcomes.

A(2) adenosine receptors regulate CFTR through PKA and PLA(2).

We investigated adenosine (Ado) activation of the cystic fibrosis transmembrane conductance regulator (CFTR) in vitro and in vivo. A(2B) Ado receptors were identified in Calu-3, IB-3-1, COS-7, and primary human airway cells. Ado elevated cAMP in Calu-3, IB-3-1, and COS-7 cells and activated protein kinase A-dependent halide efflux in Calu-3 cells. Ado promoted arachidonic acid release from Calu-3 cells, and phospholipase A(2) (PLA(2)) inhibition blocked Ado-activated halide efflux in Calu-3 and COS-7 cells expressing CFTR. Forskolin- and beta(2)-adrenergic receptor-stimulated efflux were not affected by the same treatment. Cytoplasmic PLA(2) (cPLA(2)) was identified in Calu-3, IB-3-1, and COS-7 cells, but cPLA(2) inhibition did not affect Ado-stimulated cAMP concentrations. In cftr(+) and cftr(-/-) mice, Ado stimulated nasal Cl(-) secretion that was CFTR dependent and sensitive to A(2) receptor and PLA(2) blockade. In COS-7 cells transiently expressing DeltaF508 CFTR, Ado activated halide efflux. Ado also activated G551D CFTR-dependent halide efflux when combined with arachidonic acid and phosphodiesterase inhibition. In conclusion, PLA(2) and protein kinase A both contribute to A(2) receptor activation of CFTR, and components of this signaling pathway can augment wild-type and mutant CFTR activity.

Evidence that systemic gentamicin suppresses premature stop mutations in patients with cystic fibrosis.

Here we report the effects of gentamicin treatment on cystic fibrosis transmembrane regulator (CFTR) production and function in CF airway cells and patients with CF with premature stop mutations. Using immunocytochemical and functional [6-methoxy-N- (3-sulfopropyl) quinolinium (SPQ)-based] techniques, ex vivo exposure of airway cells from stop mutation CF patients led to the identification of surface-localized CFTR in a dose-dependent fashion. Next, five patients with CF with stop mutations and five CF control subjects were treated with parenteral gentamicin for 1 wk, and underwent repeated in vivo measures of CFTR function (nasal potential difference [PD] measurements and sweat chloride [Cl(-)] testing). During the treatment period, the number of nasal PD readings in the direction of Cl(-) secretion was increased approximately 3-fold in the stop mutation patient group compared with controls (p < 0.001), and four of five stop mutation patients with CF had at least one reading during gentamicin treatment with a Cl(-) secretory response of more than -5 mV (hyperpolarized). A response of this magnitude was not seen in any of the CF control subjects (p < 0.05). In an independent series of experiments designed to test the ability of repeat nasal PDs to detect wild-type CFTR function, evidence of Cl(-) secretion was seen in 88% of control (non-CF) nasal PDs, and 71% were more than -5 mV hyperpolarized. Together, these results suggest that gentamicin treatment can suppress premature stop mutations in airway cells from patients with CF, and produce small increases in CFTR Cl(-) conductance (as measured by the nasal PD) in vivo.

Neurologic injury from undersea diving.

Underwater diving may cause several unique neurologic injuries because of exposure to rapid changes in pressure and volume. DCS, which results from extended deep dives and too rapid ascent, is a systemic disease that frequently causes spinal cord injury but may involve other organs as well. AGE results from pulmonary overpressure on ascent, with extravasation of air into the arterial system, and causes stroke-like brain injury. Both conditions are of sudden onset, progress rapidly, and require urgent attention. Definitive treatment includes administration of oxygen and recompression in a chamber. Permanent neurologic injury may result.

Negative regulatory gene for general control of amino acid biosynthesis in Saccharomyces cerevisiae.

In Saccharomyces cerevisiae, many amino acid biosynthetic pathways are coregulated by a complex general control system: starvation for a single amino acid results in the derepression of amino acid biosynthetic genes in multiple pathways. Derepression of these genes is mediated by positive (GCN) and negative (GCD) regulatory genes. In this paper we describe the isolation and characterization of a previously unreported negative regulatory gene, GCD3. A gcd3 mutation is recessive to wild type, confers resistance to multiple amino acid analogs, and results in overproduction and partially constitutive elevation of mRNA levels for amino acid biosynthetic genes. Furthermore, a gcd3 mutation can overcome the derepression-deficient phenotype of mutations in the positive regulatory GCN1, GCN2, and GCN3 genes. However, the gcd3 mutation cannot overcome the derepression-deficient phenotype of a gcn4 mutation, suggesting that GCD3 acts as a negative regulator of the important GCN4 gene. Northern blot analysis confirmed this conclusion, in that the steady-state levels of GCN4 mRNA are greatly increased in a gcd3 mutant. Thus, the negative regulatory gene GCD3 plays a central role in derepression of amino acid biosynthetic genes.

New positive and negative regulators for general control of amino acid biosynthesis in Saccharomyces cerevisiae.

The biosynthesis of most amino acids in Saccharomyces cerevisiae is coregulated. Starvation for a single amino acid results in the derepression of amino acid biosynthetic enzymes in many unrelated pathways. This phenomenon, known as general control, is mediated by both positive (GCN) and negative (GCD) regulatory genes. In this paper we describe the identification and characterization of several new regulatory genes for this system, GCN6, GCN7, GCN8, GCN9, and GCD5. A mutation in the negative regulator GCD5 was isolated on the basis of its suppression of a gcn2 mutation. The effect of gcd5 is a posttranscriptional increase in histidine biosynthetic enzyme activity. Suppressors of gcd5 which are deficient in derepression were in turn isolated. Eight such mutations, defining four new positive regulatory genes (GCN6 through GCN9), were obtained. These mutations are recessive, confer sensitivity to multiple amino acid analogs, and result in decreased mRNA levels for genes under general control. The GCN6 and GCN7 gene products were shown to be positive regulators for transcription of the GCN4 gene, the most direct-acting positive regulator thus far identified. The interaction of GCN6 and GCN7 with GCN4 is fundamentally different from that of previously isolated GCN genes. It should also be noted that these gcn selections gave a completely different nonoverlapping set of mutations from earlier selections which relied on analog sensitivity. Thus, we may have identified a new class of GCN genes which are functionally distinct from GCN1 through GCN5.

A new negative control gene for amino acid biosynthesis in Saccharomyces cerevisiae.

Enzyme levels in multiple amino acid biosynthetic pathways in yeast are coregulated. This control is effected largely at the transcriptional level by a number of regulatory genes. We report the isolation and characterization of a new negative regulatory gene, GCD4, for this general control system. GCD4 mutations are recessive and define a single Medelian gene on chromosome III. A gcd4 mutation results in resistance to different amino acid analogs and elevated, but fully inducible, mRNA levels of genes under general control. Epistasis analysis indicates that GCD4 acts more directly than the positive regulators GCN1, GCN2, GCN3 and GCN5, but less directly than GCN4, on the transcription of the amino acid biosynthetic genes. These data imply that GCD4 is a negative regulator of the positive effector, GCN4. Although GCD4 occupies the same position relative to the GCN genes as other GCD genes, it produces a unique phenotype. These results illustrate the diversity of function of negative regulators in general control.

5' untranslated sequences are required for the translational control of a yeast regulatory gene.

In yeast, many genes encoding amino acid biosynthetic enzymes are subject to a common regulatory system called the general control of amino acid biosynthesis. The product of the regulatory gene GCN4 is required for an increase in transcription of general control-regulated genes when yeast are grown under amino acid-starvation conditions. In this report, we show that the expression of the GCN4 gene is regulated at the translational level: the efficiency of translation of the GCN4 mRNA is dramatically increased during growth under amino acid-starvation conditions. The complete nucleotide sequence of the GCN4 gene, presented here, reveals the existence of an unusually long 5' untranslated region in the corresponding mRNA. In vivo analysis of the effects of a deletion in this 5' leader has enabled us to define a region required for the translational regulation of the GCN4 mRNA.

Temporal analysis of general control of amino acid biosynthesis in Saccharomyces cerevisiae: role of positive regulatory genes in initiation and maintenance of mRNA derepression.

In Saccharomyces cerevisiae, starvation for a single amino acid results in the derepression of enzyme activities in multiple amino acid biosynthetic pathways. Derepression is a consequence of increased transcription of the genes encoding these enzymes. Analysis of the kinetics of mRNA elevation established that derepression occurs within 5 min of a shift of the culture from rich medium to starvation medium. Any starvation condition was sufficient to trigger an initial high mRNA elevation; however, it was the severity of starvation which determined the steady-state mRNA levels that were subsequently established. The products of the positive regulatory genes AAS101, AAS103, and AAS2 were shown to be required in the initiation phase of this response, whereas the AAS102 gene product was required to maintain the new elevated steady-state mRNA levels. The AAS101 and AAS102 genes were cloned. Consistent with their respective roles in initiation and maintenance of derepression. AAS101 mRNA was found to be expressed at high levels in both rich and starvation media, whereas AAS102 mRNA was derepressed only under starvation conditions. The derepression of AAS102 mRNA is dependent on the AAS101 gene product.

Identification of AAS genes and their regulatory role in general control of amino acid biosynthesis in yeast.

In yeast, most amino acid biosynthetic pathways are coregulated: starvation for a single amino acid results in derepression of enzyme activities for many different biosynthetic pathways. This phenomenon is referred to as "general control of amino acid biosynthesis." In this paper we describe the isolation and characterization of 43 amino acid analog-sensitive (aas-) mutants that are perturbed in this general regulatory system. These 43 mutations define four unlinked complementation groups, AAS101, AAS102, AAS103, and AAS104, two of which identify previously unreported genes involved in general control. These aas mutants are unable to derepress a number of amino acid biosynthetic genes, resulting in increased sensitivity to amino acid analogs, reduced growth rates, and reduced enzyme activity levels under amino acid starvation conditions. Thus, the AAS+ gene products function as positive regulatory elements for this system. We show that the AAS genes mediate these effects by regulating the mRNA levels of genes under their control.

Physical evidence for a Saccharomyces cerevisiae transposable element which carries the his4C gene.

A Saccharomyces cerevisiae transposable element which carries the his4C structural gene and which is capable of transposition, excision, and mutator activity is described. Physical evidence is presented for transposition of the his4C deoxyribonucleic acid sequences to a new location in the genome and for precise excision of these transposed deoxyribonucleic acid sequences in spontaneous his4C- segregants.

Allergic conjunctival granulomas.

Seven cases are reported from Australia of benign granulomas of the conjunctiva occurring principally in children. Conjunctival granulomas of this kind have not previously been recorded in Australia. Both clinically and histologically they are identical to those described by Ashton and Cook as allergic granulomas of the conjunctiva exhibiting the Splendore-Hoeppli phenomenon.

Unstable transpositions of his4 in yeast.

Unstable transpositions in yeast have been selected in which the his4C gene from chromosome III is inserted into chromosome XII. This event is associated with the generation of a recessive lethal mutation, resulting from the integration of his4C into an essential gene. Strains with these transpositions are viable as diploids or aneuploids for chromosome XII. The event that generates the transpositions does not lead reciprocally to a deletion on chromosome III, implying that synthesis of a new copy of his4C and subsequent transposition may have occurred. The his4C transpositions are unstable and give rise to C- segregants at a high frequency, as a result of either precise excision of the his4C gene (restoring function of the gene into which insertion had occurred) or chromosome loss.